George Cheese wrote in a diary on his iPad that he was told to ‘hurry up and kill himself’ by his boss.
Photograph: INS News Agency

An Audi garage where an apprentice mechanic was bullied before he killed himself was not to blame for his death, a coroner has decided.

George Cheese’s coworkers at the Reading garage locked him in a cage, doused him in brake fluid and set his clothes set on fire, among other forms of abuse, an inquest into his death heard. One told him he should “hurry up and kill himself”.

The coroner, Peter Bedford, called some of the staff members’ behaviour unacceptable in a narrative verdict delivered on Thursday, but said the company had made significant changes. The 18-year-old’s death was attributable to numerous factors, including his fears over his health and a failing relationship with his former girlfriend, who was deemed to be blameless, Bedford said.

Cheese’s parents, Keith and Purdy, left the hearing in tears, saying they “needed time to consider the verdict”. They had told the inquest that their son was “over the moon” when he got the position at the Audi dealership, but he soon started coming home covered in bruises and had holes burned into his clothes.

Bedford, Berkshire’s senior coroner, heard details of the abuse suffered, including one occasion when four men held him down while a fifth punched his leg, leaving him with a long-lasting limp. Much of the abuse was dismissed as “banter” and “horseplay” by his then colleagues.

The inquest in Reading, Berkshire, heard that Cheese’s father saw him leave the house on 9 April 2015, at which time he had been at the garage for about six months. He was found by a neighbour in the early hours of the following morning, having hanged himself.

A few weeks later, after Thames Valley police had closed the investigation and Cheese’s possessions were returned to his parents, his mother found 14 diary entries saved in the calendar app on his iPad, describing traumatic events from his workplace. One said: “My boss told me to hurry up and hang myself because I’m a useless piece of shit.”

The line manager at the garage, Terry Kindeleit, said he did not believe the message was referring to him, but that it could have been about the master technician, Paul Clifford, who had once “gone berserk” when Cheese showed reluctance to mop the garage floor.

Cheese referred to a “PC” in his diary entries, writing: “PC tied me up, pressure-washed me. Thought it was hilarious. I couldn’t stand up afterwards. He called me a pussy and I had to walk home soaking wet.” Another entry said “PC” had approached Cheese after his parents complained to the company and called him “a pussy who went telling tales to mummy”.

Clifford told the coroner he had no memory of either event and said he did not believe Cheese had once called him his boss during their time together at work.

Bedford said he understood Cheese’s parents’ desire to blame the Audi dealership, but added that steps taken by the management following his death had succeeded in improving conditions there.

Kindeleit said mental health charity Mind had run a management course, and frequent team-building exercises had been put in place, as well as weekly employee appraisals to improve the conduct of managers and supervisors.

Bedford said: “I have to say that in the early part of Mr Kindeleit’s evidence, I was concerned about the apparent underestimation of issues that clearly took place.” But as the inquest progressed, he said he recognised that Cheese’s death clearly “came as a wake-up call and a significant shock to the garage company”.

“Senior management at the company did bring serious action against the mentor who was involved in the fire episode with George, further involvement with Mind, and a change in emphasis in further management,” he added.

Bedford stressed the other factors at play, including that Cheese may have feared he was suffering from cancer. Police discovered searches for information about tumours on his iPad and he had had terrible coughs for several months. Cheese had also suffered from some degree of mental ill health since he was 14 or 15, the coroner said.

Bedford deliberately kept Cheese’s ex-girlfriend away from the inquest because he did not believe she was responsible in any way for his death, though the difficulties in their relationship might have contributed to it.

While she did not wish to make a statement regarding the ruling, Cheese’s mother said she also felt her son’s ex-girlfriend was blameless, calling her a “darling, darling girl”.

In the UK, the Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Hotline is 1-800-273-8255. In Australia, the crisis support service Lifeline is on 13 11 14.